Civilian Extraperitoneal Rectal Gunshot Wounds: Surgical Management Made Simpler

Background Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. Methods The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. Results Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. Conclusions Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.     

Immediate postoperative complications of combined penetrating rectal and bladder injuries

BACKGROUND: Combined penetrating trauma involving the rectum and bladder has been associated with increased postoperative morbidity. Specific complications resulting from these injuries include colovesical fistula, urinoma, and abscess formation. METHODS: A retrospective review of Temple University Hospital trauma database was performed. Patients were categorized by having an isolated rectal (n = 29), isolated bladder (n = 16), or combined injury (n = 24). Records were reviewed for sex, age, site of injury, location of rectal and bladder injuries, operative intervention, fistula formation, urinoma formation, abscess formation, time to urinary catheter removal, length of intensive care unit stay, and length of hospital stay. RESULTS: Patient sex and age did not differ significantly between groups, nor was there a significant difference in location of rectal injury between groups. Presacral drainage was utilized in all patients with extraperitoneal injuries. Fecal diversion was performed in all patients, except two with intraperitoneal rectal injuries. Omental flap interposition between rectal and bladder injuries was utilized in one patient. No significant difference was noted in immediate postoperative complications between groups including fistula, urinoma, and abscess formation. However, all cases of colovesical fistula (n = 2) and urinoma (n = 2) formation were noted in those patients with rectal and posterior bladder injuries. CONCLUSIONS: Combined rectal and bladder injuries were not associated with an increase in immediate postoperative complications compared with isolated rectal and bladder injuries. However, postoperative fistula and urinoma formation occurred only in patients with a combined rectal and posterior bladder injury. Consequently, these patients may benefit from omental flap interposition between injuries to decrease fistula and urinoma formation.     

Management of civilian extraperitoneal rectal injuries

OBJECTIVE: The mortality and morbidity of rectal injuries are highly unsatisfactory. We retrospectively reviewed our experience with rectal injuries to draw some practical guidelines for management of such injuries. METHODS: The medical records of all patients diagnosed at our hospitals with full-thickness rectal injuries between 1994 and 2003 were retrospectively reviewed. RESULTS: Full-thickness rectal injuries were identified in 23 patients; 19 patients had extraperitoneal injuries and four had both intra- and extraperitoneal injuries. The mean age was 33.5 years (range, 5-73 years). The mechanism of injury was penetrating in 11 patients, blunt in six, impalement in three and iatrogenic in three. Injuries were closed primarily in 17 patients, with variable combinations of adjunct procedures. Eight patients were treated without colostomy. Drainage and rectal washout were performed in 11 and six patients, respectively. Overall, 11 patients developed complications, including eight wound infections and five pelvic septic complications related to the rectal injury. Four of the five pelvic septic complications and all three deaths occurred in patients with shock, at least two associated-organ injuries and more than 6 hours' delay in treatment. CONCLUSION: Rectal injuries are serious additive mortality and morbidity factors in multi-injured patients. Regardless of treatment modality, wound infection is associated with shock at presentation and more than 6 hours' delay in treatment.     

A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND: Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries. METHODS: All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy. RESULTS: Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed. CONCLUSION: In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.     

Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries?

BACKGROUND: Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. METHODS: This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly.A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. RESULTS: There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. CONCLUSIONS: Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.     

Diagnostic and therapeutic aspects of rectal trauma. Blunt versus penetrating

In the last 6 years, nine patients with blunt and 16 with penetrating rectal injuries were treated at University Hospital, Jacksonville, Florida. Blunt trauma was caused by vehicular accidents in seven patients and crush injuries in two. Penetrating rectal trauma was due to gunshot wounds in ten patients and foreign body insertion in six. All patients with blunt injury had bright red rectal bleeding, which led to diagnostic sigmoidoscopy. Rectal injury was identified at sigmoidoscopy in 12 patients who had penetrating wounds and at laparotomy in four patients. Thirteen patients who had penetrating rectal trauma had injury to only the rectum or to one additional organ. In contrast, all patients who had blunt rectal trauma had at least three associated injuries. In the penetrating group, 13 patients were treated by colostomy and mucus fistula; three patients with mucosal injury were managed nonoperatively. The only death occurred in a patient whose rectal injury was initially missed. Patients who had blunt rectal trauma were managed with colostomy and mucus fistula. Three patients died postoperatively, two of pelvic bleeding and one of head injury. Hemodynamic stabilization, colostomy and mucus fistula, presacral drainage, and rectal washout constitute proper treatment of patients with blunt or penetrating rectal trauma. Because of the greater number and severity of associated injuries, morbidity and mortality are higher after blunt rectal trauma.     

Surgical treatment of extraperitoneal rectal and perineal injuries

The aim of this study was to analyse the results of the treatment of extraperitoneal rectal and perineal injuries for 153 patients. All the patients were examined according to the scheme. Therapeutic-diagnostic algorithm was developed for perineal, anal, rectal injuries. Wide opening and drainage of the wound was used. The method allows to avoid colostomy and its subsequent operative closing in extraperitoneal injury of the rectum. The method of surgical treatment is recommended in extraperitoneal rectal and perineal injuries.     

Management of rectal trauma

A 9 year review of rectal trauma was conducted. Forty-seven patients had major rectal trauma requiring diversion. Twenty-seven percent of patients presented in shock. Routine perioperative antibiotics were administered. Ninety-five percent of patients had positive findings on digital rectal examination or proctoscopy. There were 91 associated injuries. Rectal injuries were repaired in 19 patients. The absence of repair had no influence on postoperative morbidity or length of hospital stay. Ninety-five percent of patients had presacral drainage. One patient had distal rectal irrigation. Both loop and divided colostomies were utilized with no difference in morbidity or hospital stay. There were no deaths. Proctoscopy is essential in patients with wounds in proximity to the rectum. Diversion and presacral drainage for rectal injury is associated with a low mortality and acceptable morbidity. Rectal washout does not appear to be essential in civilian rectal injuries.     

Diagnostic laparoscopy and diverting sigmoid loop colostomy in the management of civilian extraperitoneal rectal gunshot injuries

BACKGROUND: This prospective study reviews the management of isolated civilian extraperitoneal rectal gunshot injuries using a protocol of diagnostic laparoscopy and abdominal wall trephine diverting loop colostomy, without laparotomy, distal rectal washout and presacral drainage. METHODS: Patients admitted to the trauma unit at Groote Schuur Hospital between January 2000 and December 2002 with a rectal injury were evaluated. A rectal injury was confirmed by digital rectal examination and proctosigmoidoscopy. Missile peritoneal violation was excluded by diagnostic laparoscopy. Normal laparoscopy was followed by creation of a diverting sigmoid loop colostomy through an abdominal wall trephine, without a laparotomy. No distal rectal washout or presacral drainage was performed. RESULTS: Of the 104 patients admitted with 106 rectal injuries, 20 (19.2 per cent) qualified for inclusion in the study. All had sustained low-velocity gunshot injuries of which 18 exhibited a transpelvic trajectory. Diagnostic laparoscopy was normal and a trephine diverting loop sigmoid colostomy was performed in all 20 patients. No pelvic sepsis occurred. Two patients developed rectocutaneous fistulas, both of which resolved without surgical treatment. Nineteen stomas have since been closed. CONCLUSION: Low-velocity gunshot injuries isolated to the extraperitoneal rectum can be managed safely by laparoscopic exclusion of intraperitoneal missile penetration and diverting sigmoid loop colostomy, without laparotomy, distal rectal washout or presacral drainage     

Late-onset urethrorectal fistula after laparoscopic radical prostatectomy: report of a case

Urethrorectal fistula is a relatively rare disease. The most frequent cause of acquired urethrorectal fistulas is known to be iatrogenic complications, such as rectal injuries during the prostate operations. Rectal injuries are usually noticed during the operation and the majority can be repaired in situ. We report a case of late-onset urethrorectal fistula that lacked obvious rectal injury during the operation. Ischemic change or heat denaturation of rectal wall may be the potential cause of the present urethrorectal fistula.     

Digital rectal examination for trauma: does every patient need one?

The digital rectal examination is widely accepted as an essential component in the initial assessment of trauma. However, no data have been published that justify its routine use in all seriously injured patients. The objective of this study was to determine what if any impact on subsequent treatment and management decisions the initial digital rectal examination had on injured patients arriving at our emergency department (ED). We conducted a prospective observational study of all injured patients arriving at a Level II trauma center over a period of 6 months. A digital rectal examination was performed on all patients during the secondary survey phase of their initial evaluation shortly after arrival to the ED. The results of the rectal examination were noted for each patient with particular attention placed on the presence or absence of gross blood, Hemoccult result, prostatic examination, rectal vault integrity, and rectal sphincter tone. In addition the patient's hemodynamic parameters while in the ED and the injuries that were sustained were noted, as was their final disposition. Four hundred twenty-three patients were admitted to the ED after sustaining serious injuries. The mean Injury Severity Score was 9.96. The prostatic examination was normal in more than 99 per cent of patients; no high-riding or nonpalpable prostate glands were noted. Twenty-two patients (5.2%) were Hemoccult positive, but in none of these cases did the presence of occult blood in the stool lead to a change in the initial management or diagnostic approach. Three patients (0.7%) with penetrating injuries to the perineal/pelvic area had gross blood on digital rectal examination that prompted operative exploration to rule out a lower gastrointestinal injury. All three had rectal injuries confirmed at surgery. Rectal sphincter tone was normal in 406 (96%) patients, weak in 17 (4%), and absent in none. The only patient in whom the sphincter tone influenced management was an individual complaining of complete paralysis after a blunt mechanism of injury. He had normal rectal sphincter tone and admitted to malingering shortly thereafter. Overall the rectal examination influenced therapeutic decision making in five cases (1.2%). The digital rectal examination is unlikely to affect initial management when applied indiscriminately to all seriously injured patients during the secondary survey. Patients in whom the rectal examination may have a higher probability of influencing management are those with penetrating injuries in proximity to the lower gastrointestinal tract, questionable spinal cord damage, and severe pelvic fractures with potential urethral disruption or open fractures in continuity with the rectal vault. The Hemoccult test does not add useful information and should be discontinued as part of the secondary survey of injured patients.     

Successful management of injuries to the extraperitoneal rectum

We reviewed the records of 32 patients having extraperitoneal rectal trauma in the six-year period ending December 31, 1981. There were 23 penetrating injuries and nine blunt injuries. All patients were resuscitated and examined digitally by sigmoidoscope. Complete diverting colostomy and washout evacuation of the defunctionalized rectal segment were performed routinely. Dilatation of the anal sphincter and lavage with two to three liters of dilute povidone-iodine solution permitted cleansing of the rectal segment of all particulate fecal material. Retrorectal suction drains were inserted in 30 patients; the two remaining patients required abdominoperineal resection and gauze packing of the pelvis for control of hemorrhage. The mortality rate due to rectal injury was 3 per cent. Complications occurred in 5 patients (16%).     

腹腔镜技术在急诊直肠损伤诊疗中的应用

目的探讨在外科急诊诊疗过程中腹腔镜技术在急诊直肠损伤中应用的可行性及安全性。 方法回顾分析2015年1月至2018年1月期间急诊行腹腔镜探查及治疗的30例直肠损伤患者的病例资料。 结果30例直肠损伤患者包括，刀刺或异物刺伤13例，车祸伤10例，医源性损伤7例。所有患者均行腹腔镜探查，其中位于腹膜反折线以上18例，行单纯破损修补5例、破损修补＋乙状结肠造瘘9例、破损切除吻合4例；位于腹膜反折线以下12例，均行乙状结肠造瘘，无中转开腹。手术时间45～200 min，平均75 min；术中出血10～100 ml，平均32 ml；术后住院时间3～13 d，平均5.6 d。术后3～6月行造瘘还纳，痊愈。 结论腹腔镜技术在急诊直肠损伤中具有可行性及安全性，且简便实用、具有创伤小、术后恢复快等优点，具有推广价值。     

Colostomy and drainage for civilian rectal injuries: is that all?

One hundred consecutive patients with injuries to the extraperitoneal rectum were treated over a ten-year period at an urban trauma center. The mechanisms of injury included firearms in 82 patients, stab wounds in 3 patients, a variety of other penetrating injuries in 10 patients, and in 5 patients the injuries resulted from blunt trauma. Treatment of the rectal injury was determined by the bias of the operating surgeon, the condition of the patient, and the magnitude of the rectal injury. Proximal loop colostomies were performed in 44 patients, diverting colostomies in 51 patients, Hartmann's procedure in 4 patients, and an abdominoperineal resection in 1 patient. Extraperitoneal rectal perforations were closed in 21 patients and the rectum was irrigated free of feces in 46 patients. Transperineal, presacral drainage was used in 93 patients. Infectious complications potentially related to the management of the rectal wound occurred in 11 patients (11%) and included abdominal or pelvic abscesses (4 patients), wound infections (6 patients), rectocutaneous fistulas (3 patients), and missile tract infections (2 patients). Four patients (4%) died as a result of their injuries. Of the therapeutic options available, statistical analysis revealed that only the failure to drain the presacral space increased the likelihood of infectious complications (p = 0.03); however, as it could not be determined with certainty that the use of, or failure to use, any particular therapeutic option had an effect on the risk of death. It is concluded that colostomy and drainage are the foundations of the successful treatment of civilian injuries to the extraperitoneal rectum. The use of adjuncts such as diverting colostomies, repair of the rectal wound, and irrigation of the rectum has little effect on mortality and morbidity.     

Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures

BACKGROUND: Rectal and lower urinary tract injuries in pelvic fractures can lead to significant complications. We sought to determine whether fracture locations could serve as markers for injury. METHODS: In our retrospective review of patients with blunt pelvic fractures, the association of fracture locations with injury to the rectum, bladder, and urethra was explored with Fisher's exact test and subsequently analyzed with multiple logistic regression. RESULTS: Of the 362 patients reviewed, 8 had rectal injury and 24 had lower urinary tract injury. The following locations were found to be significant. Rectum: symphysis pubis (relative risk [RR] = 3.3, p < 0.001) and sacroiliac (SI) joint (RR = 2.1, p = 0.014). Bladder: symphysis pubis (RR = 2.1, p < 0.001), SI joint (RR = 2.0, p < 0.001), and sacrum (RR = 1.6, p = 0.002). Urethra: symphysis pubis (RR = 2.9, p = 0.003), SI joint (RR = 1.8, p = 0.04), and inferior ramus (RR = 4.6, p = 0.008). After multivariate analysis, the primary and independent predictors for each of the injuries were as follows: rectal injury, widened symphysis; bladder injury, widened symphysis and SI joint; and urethral injury, widened symphysis and fracture of the inferior pubic ramus. Although these associations were significant, the overall prevalence of associated rectal and urologic injuries was low. Consequently, the predictive values of these radiologic findings were also low, ranging from 5% to 9% for urethral and rectal injuries to 20% for bladder injuries. CONCLUSION: Certain fracture locations are associated with increased risk for rectal, bladder, or urethral injury. Fractures involving these locations should prompt further work-up for assessment.     

No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients

Digital rectal exams (DRE) are routinely used on trauma patients during the secondary survey as recommended by current Advanced Trauma Life Support (ATLS) protocols. However, recent literature has called the blanket use of the DRE on each trauma patient into question. The purpose of this study was to evaluate the efficacy of the DRE as a diagnostic tool in the setting of urethral, spinal cord, small bowel, colon, and rectal injuries and determine if it can be eliminated from routine use in the trauma setting. Trauma patients with small bowel, colon, rectal, urethral, and spinal cord injuries, age of 18 years or older, and a noted DRE were included. Exclusion criteria included an age less than 18, patients who received paralytics, a Glasgow Coma Scale (GCS) of 3, and a history of paraplegia or quadriplegia. One-hundred eleven patient records were retrospectively reviewed. Ninety-two male (82.9 %) and 19 (17.1 %) females with a GCS of 13.7 were evaluated. Sixty-two (55.9 %) injuries were penetrating with 49 (44.1) being blunt. The DRE missed 100 % of urethral, 91.7 % of spinal cord, 93.1 % of small bowel, 100 % of colon, and 66.7 % of rectal injuries. For injuries confirmed with radiologic modalities, the DRE missed 93.3 %. For injuries confirmed on exploratory laparotomy, the DRE missed 94.9 %. The DRE has poor sensitivity for the diagnosis of urethral, spinal cord, small bowel, and large bowel injury. The DRE was found to be the most sensitive in the setting of rectal injuries. The DRE offers no benefit or predictive value when compared to other imaging modalities.     

Operative Management of Civilian Rectal Gunshot Wounds: Simpler Is Better

Extraperitoneal rectal gunshot wounds have been managed with a variety of methods from simple diverting colostomy to combinations of rectal repair, proximal diversion, transperitoneal or presacral drainage, and distal bowel irrigation techniques. Treatment methodology is chosen based on anecdotal experience, and there is no clear evidence that any technique is superior to the others. The objective of this study was to compare 3 methods of managing civilian extraperitoneal gunshot wounds. Retrospective analysis of 30 consecutive patients with extraperitoneal rectal gunshot wounds was undertaken. Patients were treated with 1 of these 3 techniques: (1) simple diverting colostomy without rectal repair (group A, 12 patients); (2) diverting colostomy and rectal repair (group B, 12 patients); and (3) diverting colostomy and presacral drainage without repair (group C, 6 patients). Injury, hospital course, and outcome data were compared. The 3 groups were similar in age, injury severity, admission hemodynamics, preoperative and intraoperative time, blood loss, fecal contamination, and associated injuries. The overall incidence of complications was 27% (8/27): 25% (3/12) in group A, 33% (4/12) in group B, and 17% (1/6) in group C (p= NS). Complications directly associated with the rectal injury were found in 2 cases (7%): 1 group A patient developed a vesicorectal fistula and 1 group B patient developed a rectocutaneous fistula. For 10 patients with both rectal and bladder injuries, the complication rates for groups A, B, and C were 50%, 20%, and 0%, respectively (p= NS). No patient died. In conclusion, diverting colostomy without rectal repair or drainage appears to be safe for the management of most civilian retroperitoneal rectal gunshot wounds. Additional surgical maneuvers may be required for combined rectal and urinary trauma or other complex rectal injuries. Sound surgical principles, tailored to the individual case, should overrule any unproven dogmas.     

Impalement injury of the urinary bladder: a case report

Impalement injury of the urinary bladder, especially secondary to rectal impalement, is extremely rare. In this case, a 31-year-old man sustained a steel pipe impalement injury through his perirectal region. He presented with gross hematuria, abdominal defense, and a penetrating wound. On the basis of the computed tomography findings and abdominal defense, we suspected a through-and-through bladder perforation from the rectal space to the intraperitoneum. Laparotomy revealed a through-and-through bladder perforation as well as damage to the right ureter, 3 distinct ileal injuries, and rectal anterior, anal, and right seminal vesicle injuries. Surgical repair of each damaged site was undertaken. The prompt diagnosis and surgical repair ensured good postoperative recovery.     

腹腔镜直肠癌低位保肛电钩法技巧的探讨

目的:探讨腹腔镜直肠癌低位保肛术中使用电钩游离的手法技巧。方法:回顾分析我院2007年4月至2008年7月使用电钩游离的腹腔镜直肠癌低位保肛12例手术的效果。结果:12例直肠肿瘤距肛门6～8cm的患者行腹腔镜术,用电钩游离均低位保肛成功,手术切缘阴性,无手术副损伤及并发症发生。结论:选择Dukes分期A期、B期直肠癌,肿瘤未侵及周围脏器的患者,使用腹腔镜电钩沿正确的解剖间隙游离,能取得满意的直肠癌低位保肛手术效果。